Health and safety

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Health and safety

Kim Sunley

Chapter Contents

Introduction

It seems incongruous that a service set up to provide emergency care sometimes causes harm to the staff involved in delivering that care. In 2003, the National Audit Office carried out a survey on health and safety risks to staff in the NHS in England (National Audit Office 2003a). They reported that there were 135 172 staff accidents in 2001–2, with wide variations between similar Trusts in the number of accidents per 1000 staff. They also highlighted that there is significant under-reporting, so the true figure is likely to be much higher. In 2009 a comprehensive review into the health and well-being of the NHS workforce found that NHS staff have a greater propensity to work-related illness or accident than other comparative groups (Department of Health 2009). This is despite the complex set of statutes and regulations, some based on European legislation, designed to provide a safe environment for employees and others, such as patients, visitors, contractors’ employees and agency staff. This chapter considers various aspects of accidents at work, describes the main legal responsibilities of employers and employees, and also how this legislation is applied to hazards found in emergency departments (EDs).

Preventing accidents

The Health and Safety Executive (1993) use the term ‘accident’ to refer to any unplanned event that results in injury or ill health of people, or damage or loss to property, plant, materials or the environment, or a loss of business opportunity. Before any action can be taken to prevent accidents, the causes must be identified. Causes can be divided into unsafe conditions (e.g., wet floors, trailing cables, insufficient manual handling aids, faulty equipment) or unsafe acts (e.g., nurses’ failure to wear protective equipment or ignoring safety instructions). Unsafe acts arise from lack of training or nurses’ attitudes towards their own safety (Lynch & Cole 2006). Workplaces should be regularly inspected to check that hazards do not exist and, although trade union safety representatives have this as part of their role, it should be a cooperative process between staff, managers and safety representatives. Local policies should encourage nurses to report hazards before accidents occur so that preventive action may be taken. In fact there is a specific duty contained within the Management of Health and Safety at Work Regulations 1999 (Health & Safety Executive 2000) that requires employees to report to their employer details of any work situation that might represent a serious and imminent danger.

If an accident does occur, accurate records are needed. From the employer’s point of view there is a duty to report certain types of accidents defined within the Reporting of Injury, Diseases and Dangerous Occurrence Regulations (RIDDOR) (1995) to the Health and Safety Executive. Failure to do so is a criminal offence. The employer needs information about an accident so the event can be investigated to prevent its recurrence and risk assessments can be reviewed. Employees are obliged to report accidents and it is in their interests to accurately complete accident forms and accident books to protect themselves in the event of future loss of income or long-term effects of injury or disease.

It has always been difficult to arrive at the true costs of accidents, and yet this information could provide an incentive to tackling the problem of workplace accidents by providing a measurement against which financial loss can be judged. The National Audit Office (2003a) survey of health and safety in hospitals estimated that accidents cost the NHS ≤173 million in England alone. This is a crude estimate and does not include staff replacement costs, medical treatment costs or court compensation, so the true costs are likely to be much higher. The cost of an accident is directly related to the outcome of that accident, but this can be difficult to predict, as, for example, a needlestick injury may or may not result in a nurse contracting a blood-borne virus such as hepatitis C. The total cost of accidents must include the cost of maintaining a safe environment. A relationship exists between underlying safety control and accident occurrence.

Implementing safety controls will involve some cost, such as staff communication and training, physical protection (alarm systems), publicity campaigns, time spent in risk assessment, inspecting the workplace for hazards and maintenance of equipment. These costs will be offset by the direct and indirect costs resulting from accidents and ill health, such as occupational sick pay, equipment damage, disruption in patient care, damage to the environment, costs of replacement staff and costs of litigation. The management responsibility is to reduce risks as far as is ‘reasonably practicable’, a term used in health and safety law that is a balance between the level of risk and the time, trouble and money needed to control it.

Legislation

The health service was not covered by any health and safety legislation until 1974 when the Health & Safety at Work etc. Act was passed. This is still the major legislative power and any new regulations come under its framework. The Health & Safety at Work etc. Act (1974) specifies the duties of the employer with the general requirement to ‘ensure, so far as is reasonably practicable, the health, safety & welfare at work of all his Employees’ (Section 2(1)). The Act then specifies the particular areas where this duty applies (Box 40.1).

Box 40.1 Duties of employer in the Health & Safety at Work etc. Act 1974

• The provision of plant and systems of work that are without risk to health and safety. In addition, the equipment must be maintained so it remains safe. This could include systems of handling and moving patients, infection control procedures or extraction systems to remove hazardous fumes

• Making arrangements in the use, handling, storage and transport of articles and substances so that the risk is minimized. The safe disposal of clinical waste including sharps would be covered by this requirement

• Providing information, instruction, training and supervision so that employees are kept safe at work. General training on health and safety must be provided along with specific training on particular hazards of handling of loads and fire procedures

• Providing and maintaining a safe place of work so that there is adequate heating, lighting, ventilation and fire exits

• Provision of adequate welfare facilities. Welfare is a very broad area but could include access to occupational health services, vaccination against hepatitis B, facilities for changing, showers and toilets and a smoke-free working environment

Another section of the Health & Safety at Work etc. Act (1974) defines the duty of the employer to non-employees, including patients, visitors and contractors’ employees, to ensure these people are also protected from harm whilst they are on the premises. Systems of work must be developed to protect these groups. Floor cleaning is an example of the need to ensure that staff and others are prevented from walking on wet, slippery floors by cleaning during quiet periods, temporarily rerouting pedestrian walkways or the use of cones and warning signs.

The approach to health and safety legislation is to involve both employers and employees. The Health & Safety at Work etc. Act (1974) specifies that all employees must take reasonable care for the health and safety of themselves and others who may be affected by their acts or omissions and cooperate with the employer to enable compliance with statutory requirements. If the employer provides any protective equipment, such as gloves, goggles or aprons, the employee must wear it. This presumes the employer has defined the need for the equipment, the equipment is suitable and the employer has trained staff in the correct use.

The Health & Safety at Work etc. Act (1974) is a wide-ranging piece of legislation and one that permits further regulations to be developed that refer to specific aspects of health and safety. In 1992, six new sets of regulations were enacted that were based on EC Directives (Health & Safety Executive 1992a–e), but during that period, 1974–1995, other regulations included:

• Safety Representatives & Safety Committees Regulations (1977), which define the rights and functions of trade-union-appointed safety representatives and the arrangements for safety committees

• Health & Safety (First-Aid) Regulations (1981), which provide a framework for the provision of first aid arrangements for employees. Even in emergency departments procedures need to be defined for staff who suffer an accident

• Reporting of Injuries, Diseases & Dangerous Occurrences Regulations (1995), which specify the duty on the employer to report to the Health & Safety Executive certain categories of injuries, dangerous occurrences and designated diseases.

In the case of disease, the nature of the work is specified. Hepatitis B infection is a reportable disease for anyone who comes into contact with blood, blood products or body secretions. The regulations specify the type of dangerous occurrences that must be reported, whether or not anyone has been injured. Similarly, the specific types of injury are defined along with a broad category of any injury that results in absence from work for seven days or more. The other reportable major injuries are outlined in Box 40.2. Any incidents where a staff member has a needlestick injury where the sharp was known to be contaminated with infected blood must be reported to the Health and Safety Executive under RIDDOR.

Box 40.2 Reportable major injuries under RIDDOR (1995)

• Fracture other than to fingers, thumbs or toes

• Amputation

• Dislocation of the shoulder, hip, knee or spine

• Loss of sight (temporary or permanent)

• Chemical or hot metal burn to the eye or any penetrating injury to the eye

• Injury resulting from an electric shock or electrical burn leading to unconsciousness or requiring resuscitation or admittance to hospital for more than 24 hours

• Any other injury leading to hypothermia, heat-induced illness or unconsciousness or requiring admittance to hospital for more than 24 hours

• Acute illness requiring medical treatment or loss of consciousness arising from absorption of any substance by inhalation, ingestion or through the skin

• Acute illness requiring medical treatment where there is reason to believe that this resulted from exposure to a biological agent or its toxins or infected material

Control of Substances Hazardous to Health Regulations (2002)

The Control of Substances Hazardous to Health (COSHH) Regulations (2002) was implemented in response to concerns about the effect on health of exposure to hazardous substances and replaced and revoked the earlier COSHH Regulations (1988). Dangerous substances must be categorized in terms of hazard and risk. A hazardous substance is one that has the potential to cause harm. The risk is the likelihood that it will cause harm in the actual circumstances where it is used. The regulations require the employer to carry out an assessment of the risk and subsequently to establish a safe system of work. The definition of a hazardous substance is any solid, liquid, gas, fume, vapour or microorganism that can endanger health by being absorbed or injected through the skin or mucous membranes, inhaled or digested. One exclusion is substances administered as part of a medical treatment, although the impact on the healthcare worker would need to be assessed, for instance, during the preparation of cytotoxic drugs.

Once the assessment has been carried out, steps must be taken to prevent or at least control exposure. Elimination of the substance is the ideal solution to the problem, but there will be circumstances where this is not reasonably practicable. Glutaraldehyde, a potent cause of occupational asthma, used to be the most effective cold disinfectant available but has been substituted by less hazardous chemicals or even cold sterilization (Royal College of Nursing 2000). Examples of measures to control exposure include local exhaust ventilation, enclosing the process or, as a last resort, personal protective equipment such as goggles, masks and gloves. The regulations require the control measures to be properly used and maintained and for employees and non-employees to be informed, instructed and trained in what the risks are and how to control them.

Where nurses are exposed to risk there is a requirement to carry out health surveillance. Health surveillance is needed to protect the health of individuals by detecting adverse changes attributed to exposure to hazardous substances at the earliest possible stage. This will help in assessing the effectiveness of control measures. Where health surveillance is carried out, the employees’ health records must be kept for 30 years.

Within EDs and fracture clinics there are three main areas of risk where COSHH assessments should be carried out. The first is chemical exposure, including drugs and plaster of Paris dust. The assessment and subsequent control measures should consider storage, local ventilation, waste disposal, need for personal protective equipment, training and air monitoring. Special attention should be paid to the type of environment and the potential for patients, accompanying relatives and children to gain unauthorized access to materials such as antiseptics.

The second group of substances comprises the disinfectants such as phenolics, hypochlorites, glutaraldehyde alcohol mixtures and idophors. Many of these can be an irritant to the skin and eyes.

The third group of hazards involves the microbiological hazards from contact with blood-borne infections such as human immunodeficiency virus (HIV), hepatitis B and hepatitis C that can be found in blood and body fluids of an infected patient. COSHH requires employers to assess the risks of infection and put measures in place to reduce the risks. Standard (universal) precautions such as hand washing, use of protective equipment such as gloves and goggles and decontamination of surfaces reduce the risks to both patients and staff (UK Health Departments 1998, Royal College of Nursing 2012).

However, care must be taken when decontaminating surfaces following spillages. Chlorine-releasing disinfecting agents used in spillages of urine can be used as an example of the application of COSHH. The indiscriminate use of powdered or granular products designed to disinfect and contain spills of body fluids can lead to ill effects in staff and patients through exposure to chlorine. The use of such a substance must be controlled so it does not become a greater danger than the risk of infection. A COSHH assessment in this instance would consider both biological and chemical hazards. It would take into account the urgency of any situation, the nature of the spillage, the quantities that might be spilt and the degree of ventilation. With this information a system of work may be defined to cover storage, handling and use of any disinfecting agent, the procedure for dissolving or diluting it before use and the need for any personal protection for the user.

Legislation since 1992

Health and safety is an issue that has featured prominently in European legislation. Article 118A of the Single European Act 1986 (European Union 1986) states that member states shall pay particular attention to encouraging improvements especially in the working environment as regards the health and safety of workers and shall set as their objective the harmonization of conditions in this area, whilst maintaining the improvements made.

Directly arising out of this article was a framework directive (EC Directive 89/391/EEC 1989) on health and safety, with a number of so-called ‘daughter directives’ covering manual handling, personal protective equipment, work equipment, the workplace, temporary workers and display-screen equipment. Once these directives were agreed, European Union member states were required to include the provisions of the directives into their own law by 1992. In the UK, this resulted in a set of regulations often referred to as ‘the six pack’, comprising:

• the Management of Health & Safety at Work Regulations 1999 (Health & Safety Executive 2000)

• the Manual Handling Operations Regulations 1992 (Health & Safety Executive 1992a)

• the Display Screen Equipment Regulations 1992 (Health & Safety Executive 1992b)

• the Personal Protective Equipment Regulations 1992 (Health & Safety Executive 1992c)

• the Work Equipment Regulations 1992 (Health & Safety Executive 1992d) (replaced by the Provision and Use of Work Equipment Regulations 1998 and the Lifting Equipment Regulations 1998)

• the Workplace Regulations 1992 (Health & Safety Executive 1992e).

Although all of these have relevance in emergency departments, the first two are considered in more detail.

The Management of Health & Safety at Work Regulations (1999)

These regulations build on and make more explicit the duties of employers and employees defined in the Health & Safety at Work etc. Act (1974). The regulations originally came into force in 1992 but were amended in 1999. The main requirement is the need to carry out a risk assessment for every hazard in the workplace (Box 40.3). All of the activities and processes carried out within the emergency service should be subjected to the process of risk assessment.

Risk assessment

Employers are responsible for carrying out health and safety risk assessments; however, nursing staff should be involved in the process because they are familiar with the environment, the procedures and equipment used. Risk assessment is the starting point for total risk management. The aim is to identify where things could go wrong and what the effect would be. Risk may arise from physical hazards, e.g., unsafe flooring, poor lighting, no alarm systems, or working practices, e.g., failure to dispose of sharps safely, failure to wear gloves, failure to alter bed heights when moving patients. When carrying out risk assessments employers should:

• identify the hazards

• decide who may be harmed and how (including contractors, cleaning staff and visitors)

• evaluate the risks and decide on precautions

• record the findings and implement them

• review and update as necessary (e.g., following an accident or change to work environment) (Health and Safety Executive 2006).

Some risk assessment procedures apply numerical values to these items, which are multiplied together to produce an overall risk score, sometimes known as a risk matrix. This can be used to introduce greater objectivity and to look at relative risks from hazards, but in some cases it may be misleading. With manual handling, for example, an uncooperative patient will have an impact on the assessment. A skilled assessor, sensitive to all the variables, may produce a more useful assessment than the application of numerical values.

The process of risk assessment should result in a decision as to whether the risk is acceptable or not. If not, further work is required to control the risk. Elimination is the ideal solution but may not be always possible. Other methods of control are:

• to substitute a less hazardous process or substance

• to use engineering methods such as ventilation systems

• to redefine systems of work

• to provide personal protective equipment

• to immunize staff where possible

• to define emergency procedures.

The results of the risk assessment must be written and all staff affected must be informed about the risks and about the preventive measures or controls to be used (Clough 1998).

There are specific requirements relating to pregnant employees that were incorporated as a result of the Pregnant Workers Directive (EC Directive 92/85 EEC 1992). The risk assessment must cover any risks to the health and safety of a new or expectant mother from physical, biological or chemical agents. Where the risk cannot be avoided, the employer must alter the individual’s working conditions or hours of work. If it is not reasonable to do so or if it would not avoid the risk, the employer must offer suitable alternative employment or suspend the employee from work. Furthermore, if the employee works nights and medical evidence states that this is a health risk, the employer must provide other employment or suspend her from work.

In addition to the requirement to carry out risk assessment, the Management of Health & Safety at Work Regulations (1999) (Health and Safety Executive 2000) contain other important duties. If the assessment identifies that nurses will be exposed to risk, it may be necessary to provide health surveillance. This is needed where there is an identifiable disease related to the work and where the techniques exist to detect indications of the disease. Under these regulations the employer must appoint one or more competent persons to provide health and safety assistance. This could be one person or a team depending on the size of the organization. They may be appointed from existing employees or brought in on a consultancy basis. In any event they must have adequate time and resources to carry out their functions.

The employer must take account of employees’ capabilities, training and knowledge experience when allocating work. Training on health and safety must be given in working practices and systems introducing new equipment. The training must be repeated periodically and carried out during the employees’ working hours. Specific reference is made to temporary staff. Where agency or bank staff are used, essential information must be provided about the workplace and about any particular risks to health and safety. These regulations clearly define what is needed to develop an organizational safety culture and provide the framework within which departmental approaches are developed.

Employees’ duties

The duty of the employee to cooperate includes the use of equipment, dangerous substances, transport equipment, means of production or safety device and the need to operate these in accordance with training and instruction received. Additional duties are specified; each employee must inform the employer of any work situation which represents a serious and immediate danger to health and safety and any shortcoming in the protection arrangements for health and safety believed to exist by the employee.

This duty can be considered in the light of provisions within the Employment Rights Act (1996), which gives employment protection to employees in relation to health and safety. Employees and safety representatives have the right not to have action short of dismissal or be dismissed in the following circumstances:

• where they have been designated by the employer to carry out activities to prevent or reduce risks to health and safety and have done so or are proposing to do so

• where the employee is a safety representative and is acting in that capacity

• where the employee left the workplace because of serious and imminent danger

• where the employee took steps to, or proposed to take appropriate steps to, protect himself or others from the danger. The protection applies regardless of length of service.

Nurses are able to combine their responsibilities in The NMC Code of Professional Conduct: Standards for Conduct, Performance and Ethics (Nursing and Midwifery Council 2008) with health and safety regulations to take action to secure a safe working environment. For example, if a nurse believes staffing levels are insufficient to provide safe standards of practice, she has a responsibility to report this. It is also likely that such staffing levels would pose a risk to the health and safety of other staff and so the nurse would be required to report this under health and safety legislation.

Manual Handling Operations Regulations (1992)

The impact of manual handling on the health of nurses has long been recognized, but these are the first set of regulations to address the problem specifically. In the NHS sickness absence due to musculoskeletal disorders accounts for around 40 % of all sickness absence (NHS Employers 2009). Musculoskeletal disorders, including back injuries, are the main cause of ill health retirements in the health sector (Department of Health 2009).

The Manual Handling Operations Regulations 1992 (Health & Safety Executive 1992a) require the employer to avoid the need for employees to undertake any manual handling operations at work that involve a risk of injury. This is qualified by the phrase ‘so far as is reasonably practicable’ and where this applies the employer must carry out an assessment to reduce the risk to the lowest level reasonably practicable. The regulations cover both animate and inanimate objects. The approach in the risk assessment is based on ergonomic principles of optimizing the fit between the nurse and her work.

The guidance to the regulations identifies four factors for the assessment:

• the task

• the load

• the environment

• individual capability.

These factors are interrelated and may not be considered in isolation. No one working in a hospital should put their safety at risk when moving or handling patients. Risk assessments should identify what equipment, e.g., hoists or sliding aids, are needed to reduce the risk of injuries. Patients should be encouraged and allowed to move independently and contribute to the movement. A patient handling policy should be in place that commits to reduce the risk of injury as far as possible and to meet the needs of the patient and protect the staff from risk. Examples of the risk factors under the four headings are summarized in Box 40.4. Once the risk factors have been identified, the next stage is to take steps to eliminate or reduce the risk. Possible control measures are summarized in Box 40.5.

The assessment will take place at two levels. First, the workplace itself must be assessed by the department manager in conjunction with any specialist help. This assessment will take into account departmental accident and absence statistics, layout, availability of handling aids and training of staff. Once completed, the risk-reducing actions are likely to have been identified and action plans developed.

The particular needs of the nature of the work make a difference to the assessment. In emergency areas, it would be appropriate to develop generic assessments for many of the transfers that take place, e.g., trolley to bed, wheelchair to bed. In emergency situations, an on-the-spot assessment is needed by skilled staff to judge whether the generic assessment is relevant. The risk assessment must be written and should be available to staff who need the information. If circumstances change so that the assessment is no longer valid, it must be updated.

The next level of assessment is in relation to individual patients. In wards or in the community, a manual handling assessment would be incorporated into the patient care plan. Within EDs a system should exist that would enable an initial manual handling assessment to be carried out; this would need updating as the patient’s condition and treatment are known.

The duties of the employee under these regulations are to make full and proper use of the systems provided by the employer. Nursing staff have a responsibility for their own actions and their own competence. Where training on manual handling is available the nurse should attend. If the training is not provided, the nurse should be requesting that she has the opportunity to receive this training.

Infection prevention and control

Infection control is particularly important within EDs because the status of each patient arriving in the department will not be known and treatment may be necessary before there is any indication that the patient may present a risk. Specific local infection control policies are needed in relation to cleaning and decontamination of the workplace, use of disinfectants, hand washing, dealing with laundry, protective clothing, disposal of waste and transport of specimens.

Contact with patient’s blood/body fluids carries with it the risk of occupational exposure to blood-borne infections such as HIV or hepatitis B or hepatitis C. Healthcare workers need to follow standard (universal) precautions to prevent contamination by blood/body fluids. These precautions include covering any abrasions to exposed skin, wearing gloves and plastic aprons, thorough hand-washing between procedures, and wearing eye protection if there is any risk of blood splashes or flying contaminated debris.

Accidental inoculation or splashes to the eyes or mucous membranes with infected blood present a real risk to the nurse although for most incidents there will be no harm to the nurse. However, sharps injury is a major cause of transmission of blood-borne viruses from patient to nurse. The Health Protection Agency (2008) reported that there had been 14 hepatitis C sero-conversions following significant exposure over a ten-year period and five HIV sero-conversions since 1999. Extreme care is needed with the use and disposal of sharps, and used sharps should never be recapped or re-sheathed. Risk assessment must be carried out and safer systems of work implemented. There are now technological solutions, with a wide range of safety-engineered devices that can significantly reduce the risk of a needlestick injury.

In the event of a needlestick injury, the immediate action is to make the puncture wound bleed by gentle squeezing of the area. Wash thoroughly with soap and water and apply a waterproof dressing. If the source patient is known, a record should be kept with the name of the patient. In any event, contact should be made with occupational health and an accident form completed. Procedures should be defined for spillages of blood and body fluids including COSHH assessments for the chemicals used to deal with spillages. A new European Directive (EC Directive 2010/32/EU 2010) on the prevention of sharps injuries to healthcare workers is due to be implemented by European member states by May 2013. The Directive places specific requirements on healthcare organizations to assess the risk of injuries to staff and put measures in place including safety engineered devices to reduce the risk of needestick injuries.

HIV

The most likely method of transmission of HIV to ED staff would be through inoculation of infected blood by a sharps injury or exposure of mucous membranes to blood. This reinforces the need for staff to adhere to the standard precautions. All patients attending an ED should be approached in the same way as far as infection control is concerned. If a nurse suffers a needlestick injury, blood samples for storage and possible testing for HIV antibodies must not be taken from the injured nurse or the source patient without informed consent and pre-test counselling. It is essential that the injured nurse follows local policies and seeks prompt expert advice following an injury so any necessary post-exposure prophylaxis can be commenced without delay.

Hepatitis B

Hepatitis B has been known to be a problem to healthcare staff for over 20 years, and recently other strains of hepatitis have been identified. Hepatitis B is a stable virus, resistant to common antiseptics, and is therefore highly infectious. Hypochlorite, glutaraldehyde, chlorine and autoclaving at 134°C for a minimum of three minutes are known to destroy the virus (Royal College of Nursing 2000).

In EDs it is most unlikely that there will be any indication that a patient is infected with hepatitis B. It is advisable that all staff are vaccinated with the hepatitis B vaccine in accordance with Department of Health guidance (Department of Health 2007a).

The risk of transmission to a healthcare worker from an infected patient following such an injury has been shown to be around 1 in 3 when a source patient is infected with hepatitis B virus and is ‘e’ antigen positive, around 1 in 30 when the patient is infected with hepatitis C virus and around 1 in 300 when the patient is infected with HIV (Department of Health 2008).

Although risk of transmission of blood-borne infection from staff to patients is low, there are restrictions on working practice in place for staff that are infected with HIV, hepatitis C RNA-positive or hepatitis B e-antigen positive. Guidelines also require checks on viral loads to be made on healthcare workers who are e-antigen negative and perform exposure prone procedures. Exposure-prone working practices should be restricted, i.e., those where the worker’s gloved hands may be in contact with sharp instruments, needle tips and sharp tissues, such as spicules of bone or teeth, inside a patient’s open body cavity, wound or confined anatomical space where the hands or fingertips may not be completely visible at all times (Department of Health 2002, 2005, 2007b). It should be noted, however, that this policy is currently under review (Department of Health 2011).

Working Time Directive

It is clear that the organization of work in EDs, which normally provide a 24-hour service, is a factor that can have an impact on the health of staff. Working time had not been covered specifically by health and safety legislation until the European Directive on Working Time was agreed in 1993. The UK introduced regulations to implement the directive in 1998. The Working Time Regulations (1998) phased in the provisions for junior doctors. Since 2009 average working week for junior doctors has been reduced to 48 hours, which brings them in line with nurses. The basic provisions of the directive are outlined in Box 40.6.

Box 40.6 Basic provisions of Working Time Directive

• Entitlement to a rest break of 11 consecutive hours per 24-hour period

• Entitlement to an uninterrupted rest period of at least 24 hours per 7-day period. These provisions may be varied for healthcare workers provided that equivalent compensatory periods of rest are arranged

• Weekly working time including overtime must not exceed 48 hours. This can be averaged out over a period of 17 weeks or longer by agreement

• Normal hours of night work may not exceed an average of 8 hours in any 24-hour period. This can be averaged out over a period of time as agreed through collective bargaining

• Night workers are entitled to a free health assessment prior to starting night work and then at regular intervals

• Night workers suffering from health problems recognized as being connected with the fact that they perform night work are to be transferred to day work wherever possible

• Records of night workers are to be maintained and provided to competent authorities on request

All workers are entitled to four weeks paid annual leave. The implementation of the Working Time Directive (EC Directive 93/104/EC 1993) is likely to mean that working patterns and hours of work will be the subject of negotiation between employers and their employees, but the key purpose is to ensure that the arrangements do not have a detrimental effect on the health of staff.

Framework for maintaining a safe environment

Health and safety is covered by extensive legislation aimed at producing working environments that are safe for both nurses and patients. The legislation must be translated into practical policies which are known and understood. The main employer must have an overall safety policy but particular areas should have departmental policies which address problems in those areas. In EDs, specific policies may be needed for manual handling, dealing with violence and aggressive behaviour, disposal of clinical waste and infection control. Each member of staff, whether clinical or not, should be clear about her responsibility for health and safety.

Procedures should be defined in the event of any accident taking place, from immediate first aid to the reporting procedures. The policy should specify the consultative arrangements that may exist. Normally this would be a safety committee with management and trade union safety representatives, along with specialist support such as occupational health and safety adviser, infection control and radiation protection adviser. Safety problems that cannot be resolved within the department should be addressed by the safety committee. Regular monitoring, such as health and safety audits, needs to be carried out to ensure that policies and risk assessments are effective.

Violence

In 2003, the National Audit Office carried out a survey examining the impact of violence and aggression in the NHS. This report demonstrated a rising incidence of violence and aggression and made wide-ranging recommendations (National Audit Office 2003b) (see also Chapter 12).

Following this survey, the NHS Security Management Service, now called NHS Protect, was established and given the operational and policy remit for security in the NHS (England) in 2003. It has developed a strategy which is being implemented. The key elements are:

• a national syllabus on conflict resolution. It is intended that all frontline NHS staff should have the opportunity to attend this training

• a national system for reporting physical assaults to the Security Management Service

• the appointment of local security management specialists in every trust with a programme of professional training

• the establishment of a Legal Protection Unit that will advise and support trusts in pursuing private prosecutions of offenders where the police and/or the Crown Prosecution Service take no action (Security Management Service 2003).

Across the UK there are a number of strategies in place to address the risk of violence against nurses and other healthcare workers including the Emergency Workers (Scotland) Act (2005) that makes it a specific offense to assault a nurse or other frontline staff who is delivering emergency care.

In a Royal College of Nursing Survey (2006) on nurses’ working environment, nearly eight out of ten nurses working in emergency departments report having been assaulted in the previous 12 months and 95 % reported experiencing verbal abuse at some time in their career. Violence is a complex problem with a range of causes, but clearly this is a significant risk in EDs with the potential for interaction with those whose behaviour is influenced by drugs or alcohol. The Management of Health and Safety at Work Regulations 1999 require the application of the risk-control approach to prevent as many incidents as possible by the use of technology such as CCTV, alarm systems, security staff and the design and layout of the environment. Medley et al. (2012) also found a correlation between ED crowding and higher rates of violence towards staff. It is unlikely that all incidents can be prevented, so systems are needed for supporting staff, reporting to the police and ensuring that there is a clear message to the public that violent and aggressive behaviour will not be tolerated.

Stress

The Health and Safety Executive (2005) reported that nurses, particularly in the public sector, are one of the occupation groups with the highest prevalence rates of work-related stress. The management of stress should be approached in the same way as any other health and safety hazard: identify the hazards, assess the risk, implement the control measures and review. The Health and Safety Executive has developed a set of six Stress Management Standards – called dimensions – to identify and tackle work-related stress. If the six dimensions are not properly managed they may become sources of workplace stress. These dimensions are:

• demands – such as workload, working patterns and the working environment

• control – the extent to which individuals can control the way they do their work

• support – level of support from the organization, line managers and colleagues in terms of encouragement, resources

• relationships – such as promoting positive working to avoid conflict and dealing with unacceptable behaviour

• roles – understanding roles within the organization and avoidance of role conflict

• change – management and communication of organizational changes.

The Royal College of Nursing (2006) incorporated these scales into a survey of nurses’ working environment and found that nurses working in EDs scored most negatively compared with other groups, indicating that working in this specialty can result in workplace stress. The survey also used a measure of psychological wellbeing, and nurses working in emergency have poorer psychological health scores than those working in other areas of hospitals. Poor staffing levels leading to high workloads are a cause of stress in the nursing workforce (Royal College of Nursing 2010).